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Mana Whanonga Pirihimana Motuhake

Examination of Police actions following a report of a missing mental health patient

16 October 2020

On 30 August 2018 Northland Police were notified that a male subject to a community treatment order was overdue his medication and was missing. He had last been seen on 24 August 2018. The officer who was assigned the missing person file went on leave the same day and the file was not reassigned.

The man stole petrol from various petrol stations between 26 August and 7 September 2018. He was located and arrested in Upper Hutt on 19 September 2018.

The appropriate mental health agencies were notified of the man's arrest and told he had been reported missing by a registered mental health nurse, was subject to a treatment order and he would be released on bail by Police in the absence of grounds to detain him further. Police were told that a mental health crisis team would not attend the Police station to see him, but that he could make his own way to an emergency department, which he did not do.

On 20 September 2018 the man repeatedly stabbed and killed a work colleague in an unprovoked attack. He was subsequently found not guilty of murder by reason of insanity but ordered to be detained as a special patient.

Police investigated their own actions and found that the missing person file should have been reassigned when the original officer went on leave. Also, there was insufficient liaison with Northland DHB after the man had been reported missing, and a number of enquiries that may have led to him being located earlier were not considered or completed.

Police were found not to be at fault in relation to the man's release from custody and could not have reasonably foreseen his actions of 20 September 2018.

Northland Police has since reviewed its missing person processes and undertaken to develop a more robust model of missing person file management that considers existing policy and procedure, leave and competing demands. This will ensure that there is appropriate oversight of missing person files at all times.

The Authority agrees with the outcome of the Police investigation and notes that the matter is also being considered by the coroner.

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